Can it be any hotter in here? This hallway feels like a sauna. No. Wait. I am just nervous. And I am wearing a tie. That is a first. Have not come anywhere close to formal wear in the last seven months. It is maroon and crimson. The tie. The only one I brought with me to Rwanda. Some repeating pattern of small crests, the defining features of which I cannot quite make out. It does not belong to any university or sports team because I do not own any ties like that. At least this conversation with myself is distracting me from the more pressing issue: the heat.
Nowhere to sit down outside his office. I see two chairs and both are occupied by middle-aged women. I recognize one of the women from my village, but I always seem to forget her name. G______? B______? Hopeless. The name won’t come to me; the heat won’t go away. Distraction. I knock and enter the office door.
Is Dr. A_______ in?
No. He will be back shortly.
Great. Shortly. One does not have to spend a lifetime living in East Africa to know that “shortly” has no definitive end points. Five minutes? Five hours? Five days? Stop. Frustration only leads to…yep, there it is. Sweat. Now, I am sweating. It is almost midday. It is really sunny outside1. A team of nurses rounds the corner. I smile. They smile back. Maybe I should have texted him in Kinyarwanda. Not that mine is perfect but maybe the times were mixed up in translation2. Unlikely. T_____ took care of that, and she speaks both fluently. Well, at least Kirundi, which is mutually intelligible with Kinyarwanda3. I trust that the appointment was set at the appropriate time. Calm. Be calm. I lean against the wall opposite his door. My mind turns to my surroundings. White walls. Concrete floors. The buzz of distant conversation—unintelligible for a number of reasons. No smells other than that all too familiar smell of sanitizer and (my) sweat. I do not like it. Is the hospital really a place for me?
Some time passes, though I cannot say how much, before Dr. A_______ appears. Impeccably dressed. A bright purple dress shirt, gray slacks, and a pristinely white white-coat#. I introduce myself and follow him into his office. We do not stay there long. Only long enough for me to survey the room. I glance at some of the other white coats. I recognize the framed papers on the wall as diplomas. Some folders and pens are scattered on a small wooden office desk.
He is a man of few words. I guess my limited language skills make me one too. We exit the office and quickly pass through the waiting area, my temporary residence for the past few hours, and move deeper into the hospital complex. We continue through a set of double doors and sunlight assails# us. For a moment, I am drawn back to memories of high school and brisk walks, taken between classes, along covered walkways, which enclosed well-kept gardens, finely manicured lawns, and elegantly designed brick buildings. They—those people in suits who talked at graduations and public assemblies—always used to talk about this idea of education as a pathway to success in life. Is that why we had so many sidewalks?
I can see that we are approaching the central plaza. A large tree stands in the middle. I have never been able to identify trees properly—or any plants for that matter—so I should not try now. I can only tell you the olive green leaves’ appearance resembles that of misshapen hearts, and the wood’s rough and grainy exterior suggests a personal history much older than its surroundings. A fine gravel path winds around the tree in a circle serving as a conduit for transporting patients to the appropriate destination: obstetrics, general clinic, surgery, emergencies. I do not see any vehicles. Not sure how this fits into the functional/operational framework of the hospital, but I am also not sure of much of anything at this point. We never make it to the circle and instead make another right and make our way to salle d’urgence.
I do not speak French, but all the signs are there to tell me that we have arrived in the emergency department. The weariness in the eyes of the men and women seated outside only begins the prologues about stories that completely overshadow any discomfort I might have felt earlier while waiting for the doctor to arrive. As we bypass the line and make our way to the door, I can feel countless eyes centered on me. My intuition guides me in that these stares are not filled with malice but rather curiosity. I am dressed “professionally#,” and questions of my presence begin entering my head. What is this muzungu# doing here? Has he come to help us? Do I have it in me to tell them I have come here to watch? That the nature of medicine intimately connects me with the forces that sap life from the Earth and its people, and that I have flown over seven thousand miles to see how the other half dies?
I do not say anything. I am not sure I even manage a smile. I just focus my eyes on the back of the doctor’s head and follow him into the ER. The emergency department consists of four rooms: reception, exam room, and two rooms with seven occupied beds. As we enter reception, we greet the doctor and nurses on staff. Dr. A_______ exchanges a few words with the attending physician, a Congolese gentlemen who I later learn is the only doctor in the entire hospital. Despite my best efforts, I only gather a few words. But the Congolese doctor’s occasional nodding seems promising. Dr. A_______ smiles and leaves.
I muster up words that communicate that I speak a little Kinyarwanda and can manage to comprehend basic French. The latter is an overstatement# as my comprehension relies largely on the few classes I have taken and whether or not the root word matches structure and meaning of vocabulary found in Spanish—a romance language with which I am more familiar. The Congolese doctors smiles and calls to an assistant, who quickly gets out of his seat, takes off his own white coat, and insists that I wear it and take his place. I make a plea for him—the qualified and capable individual—to take it back and sit down, but he refuses (and not for lack of understanding because he is talking to me in English and converses rather fluently). Great. Now, I am sure to make an impression.
Our (my) first patient enters. The doctor opens the encounter with an inquiry. The patient begins telling us why he does not feel well. I imagine that I look more perplexed than actually engaged. I am trying so desperately to follow the conversation that perhaps I even look constipated. While I have not yet mastered Kinyarwanda, I know enough to distinguish between Kinyarwanda and Kiswahili, and I quickly discover that the Congolese doctor is speaking to his patient in Kiswahili and some are responding in the same vein or incorporating a combination of Kinyarwanda, French, and Kiswahili. It is not uncommon for many educated individuals in Rwanda to speak three or more languages, but the doctor’s choice to speak to his patient in his non-native language unsettles me. We travel to the adjacent room for a brief physical exam. Before I settle in and orient myself, the patient is out of the door, and the next is waiting in reception.
And it continues in this fashion. My efforts to engage wax and wane. Occasionally, the Congolese doctor explains a clinical process to me in French. I nod indicating a comprehension that does not exist. My eyes dart around the room and my mind runs through thoughts and visuals faster than I can process. The smell of feces. Why hasn’t someone cleaned that up? Blood on the sheets. Not sure it even belongs to the patient. Loud breath sounds. My own breath? No. There is a small child in the corner. An elderly woman seated on the side of his bed. Cerebral malaria. The doctor is saying something, but these are the only two words that stick. Nothing to do but wait and hope at this point he says. The boy has passed through our realm of influence. We can only reach out and hope he finds his way back. In the interim, we watch and wait. I watch the fall of his chest and anticipate the rise. I wait—holding my own breath—in those seemingly endless seconds.
I remember almost drowning. I was nine years old. I do not remember what the wave looked like. Just that feeling. That sensation of grasping for any available oxygen in the air. I remember my cells screaming to my nerves that something was wrong. My nerves crying out to my brain to make sense of a world devoid of air. The tide denying my efforts to find the surface. And at that precise moment when panic sets in, I remember emerging and reveling in the abundance of this incredibly precious element. And this is the experience I draw on to empathize with the young boy in front of me. Eyes in the back of his head. Ribs exposed. Chest rising and falling rapidly, occasionally halting entirely as the respiratory muscles fail to consume enough oxygen to function. Caught in a continuous process of gasping for air, his body has already shut down all processes (including consciousness) and reverted to our most basic animal instinct: survival.
I want to say that we are connected somehow. That I understand his plight. Empathy is about shared experience, or at least, using my mind to imagine a world in which I am not myself. Not only am I not myself, but I am, in fact, someone else. My mind remains wrapped up in this idea of presupposing that I do or ever will understand the experience of the boy in front of me. Is it arrogant of me to believe that I can walk with this child as he travels through places I dare not try to describe for fear of not doing justice to the descriptions? Places where adjectives fail to create accurate images for the horrors and terrors that assault (literally) his mind. I want to hold his hand and tell him everything is going to be ok. But I do not know that it will. And I am burdened by the compelling desire to do something and the upsetting reality of the insurmountable obstacles—in this case, insufficient medial knowledge and inadequate language proficiency. I do not have the skills or drugs or magical ability to do anything to help this child.
This is why I chose medicine as my profession. Right? I know that I am ready to have the clinical expertise. However, I cannot say I am prepared for the process through which I will acquire such skills nor the idea that I will fail some of my future patients. I remain unsettled as I reflect on the child’s harrowing demise and catalogue it as an educational opportunity—indeed, a very self-serving one. The first of many such experiences in which I will sit and watch, listen, observe, and discuss all in order to understand a condition or disease. My instructors will insist that my colleagues and I be sure to incorporate medical jargon to characterize the specific nature of what we see before us. We will compare notes and review the literature. We will learn to confine our reports to specific descriptions and scientific explanations. If we are lucky enough, we will make some contribution to this growing body of knowledge and the process will carry on. Too often, what I will not be asked to do is to imagine. To embark on an expedition into my own mind and to probe deep into my consciousness to conjure up images, symbols, and words that can decipher what is before me. Language that can help me make sense not just of my world but that of the young boy dying in front of me.
I see his grandmother sitting on his bedside, and she sees me. I do not know if she stares as deeply into my dark brown eyes as I do into hers. We only hold each other’s gaze for a moment. I am nervous and choose to look again at the child. I cannot return to looking at her face. The child’s rapid coarse breathing transforms simple facts of life, of my life, into gifts I did not know I had been given. I take simple facts of life for granted. I like to imagine that the grandmother and I have arrived at the same conclusion: that the difference between life and death too often amounts to nothing more than chance. That it does not make any rational sense that we—the grandmother and I—should live and the child should die. I feel overwhelmed and leave the room and return to reception.
It is early evening when I leave the hospital. The sun is still shining. The heat is still radiating. I walk the few blocks to the bus station and shuffle into the cramped vehicle with everyone else. We wait. It is not long before I start sweating. I loosen my tie and unbutton the top button of my shirt. A refreshing cool air rises up over the green hills and whirls through the window. I breathe. I breathe in deeply and exhale slowly.
1Scattering light rays enter hallways and rooms of the hospital through its many windows and open doorways.
2Learning to tell time in East Africa requires that one add or subtract six hours from the conventional Western time reference frame as saa moya, the “first hour” of the day, corresponds with seven in the morning in Rwanda. In the West, we decided that the middle of the night might more appropriately be described as the first hour. Huh?
3The linguistic similarity owing to the fact that Rwanda and Burundi were once the same country: Ruanda-Urundi. Ethnically, the two countries are nearly identical with the Bahutu, Batutsi, and Batwa making up the three predominant groups.
4I never cease to be amazed at how standard hand washing of clothes can produce such spotless and sparklingly white articles of clothing.
5Those extra sunrays only intensify my episodes of profuse perspiration.
6A contemporary point of contention among medical providers, as some insist that the pompous nature of dark suits, pressed shirts, and expensive ties contradicts the emerging paradigm of patient-centered care. Such style of dress distances physicians from their patients, especially those from urban and economically disadvantaged communities.
7Literally translates as “white person.” Despite being half-African, I am clearly not from around here.
8If not an outright lie…